Breast is Best – except when it isn’t

By that I mean I am 100% in favor of giving mothers all of the necessary information and resources to have the best chances of successfully breastfeeding if they so choose.

I’m conflicted, though. A lot of pro-breastfeeding rhetoric sets up many mothers for a lot of unnecessary guilt and pain.

For example, take the first sentence on the World Health Organization’s breastfeeding page: “Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development.”

In other words, if you have trouble breastfeeding, you’re not normal.

The second sentence is worse: “Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large.”

If you have trouble breastfeeding, you’re not normal, AND you’re probably not trying hard enough.

If you have trouble breastfeeding, you’re not normal, you’re probably not trying hard enough, AND you’re clearly ruining your child.

This is dramatic. I get it. Except, it’s kind of not. Scientific literature tells us that breastfeeding saves thousands of lives, and that it’s our duty to breastfeed in case of another Holocaust (actual quote: “Our role as caretakers is to prepare for [disasters] and not compound their consequences by disrupting the natural order of infant feeding (e.g., breastfeeding and the use of human milk). […] Those infants who were born into the horrors of the Nazi camps and survived proved it, and that should be enough to convince the doubters”). Even without those extremes, I know many women who have experienced significant amounts of guilt about not producing enough milk, not being able to nurse, and/or needing to supplement or switch to formula entirely.

There are a number of reasons women are unable to exclusively breastfeed, or choose not to do so. Here are a few:

Aside from the fact that, in this day and age, lack of family and employer support and lack of information are a damn shame, all of these (and many others) are perfectly legitimate reasons to choose formula or supplementation. And while there are a number of studies demonstrating the benefits of breastfeeding to both mother and baby, there are also studies showing those benefits may be negligible at best. Why, then, must we always talk about breast-feeding as easy and natural and any other form of feeding as less-than?

One very important answer to that question is that society has not entirely caught up with women’s rights. We need to emphasize the importance of being able to choose breastfeeding in order to guarantee working mothers rights to adequate space and time to pump, and to protect the rights of all mothers to breastfeed whenever and wherever they need to do so.

All too often though, the voices speaking out to protect women’s right to choose to breastfeed turn that choice into an imperative. It’s really, really hard to defend the value of breastfeeding in a way that is strong enough to combat an employer’s or an anti-NIP mega-prude’s ability to say “just use formula instead,” without overselling the benefits of breastfeeding in a way that implies that mothers who have difficulty breastfeeding or choose to use formula are failing their babies.

So we have a very real need to tout the very real benefits of breastfeeding in order to protect the rights of women to choose (breastfeeding), while also navigating a very real need to not exaggerate the actually maybe-not-so-significant benefits of breastfeeding in order to protect the rights of women to choose (not to breastfeed).

Now that we’ve muddied those waters, let’s further complicate this mess by adding in medical complexity. When you add in prematurity and chronic illness, all of that muddiness is amplified. More is at stake; the potential benefits are more significant, and the potential pain is greater.

Let’s say there’s a mother, we’ll call her “A,” who has an infant son, let’s call him “L,” who gets most of his nutrition from TPN. A was really looking forward to breastfeeding, which she expected to come naturally for her, but instead L was born with a gastrointestinal condition that made him unable to nurse for months after birth. A pumped freezers full of milk, determined to make nursing work sooner or later (because how could she ever create a strong bond without nursing? She would definitely never end up with a mother-obsessed toddler who must not only sleep in the same bed as his mama, but also on the same pillow….) or at the very least provide enough breastmilk to get him through as long as possible, since she’d been told breastmilk would aid in gut rehabilitation.

Let’s say that when L was about 7 months old, a less-than-helpful gastroenterologist made A feel like all her pumping was essentially futile because L still wasn’t drinking all that much, and she already had more than enough breastmilk in the freezer to get him well past his first birthday. And then, let’s say when L was about 15 months old, he started a downhill slide that ended in an emergency blood transfusion and a return to TPN, and that just happened to coincide with A’s freezer stash running out.

Any number of things could have contributed to that downhill slide – the most obvious answer, which seemed pretty clear to L’s new, more supportive GI team, is that he wasn’t ready to be off of TPN just yet – but with all the breastmilk rhetoric out there, you can bet your buttons A will wonder for the rest of her life if she should’ve just kept pumping. Because maybe that downhill slide was all her fault.

Or, consider a mother who gave birth to a 24-weeker and was unable to induce lactation with a pump. A few weeks into their NICU stay, her preemie develops necrotizing enterocolitis (NEC), a devastating disease that destroys the bowel. She already feels like she’s failed her baby several times over, since she was unable to carry him to term and was unable to lactate and can’t even hold him when he cries silently around his vent tube, and she’s trying to wrap her head around a diagnosis she can barely pronounce, and now she’s being told by science and the WHO and a holier-than-thou crusader of a lactation consultant and all of the women in the organic foods aisle that breastmilk prevents NEC, so by the transitive power of sanctimommy her baby’s condition which will plague him for the rest of his life is her fault. Her baby MIGHT ACTUALLY DIE because she couldn’t convince her nips to give up the all-natural goods.

The thing is, in any individual case, you can’t know if breastmilk or formula made a difference. I can’t go back and try again with L to see if keeping him on breastmilk longer than 15 months would have produced different results. It probably wouldn’t have, but I can’t know, and so there will always be guilt.

Moms in our online short gut group who attribute their babies’ positive outcomes to breastmilk – they can’t know if their baby would have had worse results on formula. Moms whose preemie and short gut babies have struggled greatly on formula – they can’t know if their baby would have had better outcomes on breastmilk.

Overall, yes, studies have shown that breastmilk is better for preemie populations, and so it really is very important to encourage moms to try to pump and provide them all the support they need to do so. But how do you continue encouraging mothers to try everything in their power to pump enough milk for their babies to feed exclusively on human milk, because maybe it could save their lives (although maybe in any particular case it would make little real difference), without making those same mothers feel like their baby’s struggles are all their fault if they can’t produce milk, when they already feel like they have failed at the fundamentals of motherhood?

I don’t have an answer. But I do know that the answer is not a careless chorus of “Breast is best.”

Like this:

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2 thoughts on “Breast is Best – except when it isn’t”

Just want to thank you for this post. My son had to be delivered at 29 weeks due to my own potentially-life threatening complications. I never started lactating because he was born so early, but even if I had, it’s questionable whether I could have nursed safely, given the meds I was on to deal with the after effects of those complications–as well as for anxiety, since early in my pregnancy, our house burned down and we lost everything we owned (as if having a preemie in the NICU weren’t enough to trigger anxiety on its own). (Side note: the number of NICU nurses who asked if we had a nursery ready at home when we didn’t have a home to bring him to, on top of not being able to carry him to term…yes, you could say there was some guilt there.) Messages like the one in your post are so important, and I’m so glad you put it out there. Again, thank you.